Physical Assessment
Nursing assessment is an important step of the whole nursing process. Assessment can
be called the base or foundation of the nursing process. With a weak or incorrect
assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating
wrong interventions and evaluation. To prevent those kind of scenarios, we have created a
cheat sheet that you and print and use to guide you throughout the first step of the nursing
process.
Physical Assessment
Integument
Skin: The clients skin is uniform in color, unblemished and no presence of any
foul odor. He has a good skin turgor and skins temperature is within normal limit.
Hair: The hair of the client is thick, silky hair is evenly distributed and has a
variable amount of body hair. There are also no signs of infection and infestation
observed.
Nails: The client has a light brown nails and has the shape of convex curve. It is
smooth and is intact with the epidermis. When nails pressed between the fingers
(Blanch Test), the nails return to usual color in less than 4 seconds.
Head
Head: The head of the client is rounded; normocephalic and symmetrical.
Skull: There are no nodules or masses and depressions when palpated.
Face: The face of the client appeared smooth and has uniform consistency and
with no presence of nodules or masses.
Eyes and Vision
Eyebrows: Hair is evenly distributed. The clients eyebrows are symmetrically
aligned and showed equal movement when asked to raise and lower eyebrows.
Eyelashes: Eyelashes appeared to be equally distributed and curled slightly
outward.
Eyelids: There were no presence of discharges, no discoloration and lids close
symmetrically with involuntary blinks approximately 15-20 times per minute.
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Eyes
o The Bulbar conjunctiva appeared transparent with few capillaries
evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.
o Cornea is transparent, smooth and shiny and the details of the iris are
visible. The client blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat and
round. PERRLA (pupils equally round respond to light accommodation),
illuminated and non-illuminated pupils constricts. Pupils constrict when
looking at near object and dilate at far object. Pupils converge when
object is moved towards the nose.
o When assessing the peripheral visual field, the client can see objects in
the periphery when looking straight ahead.
o When testing for the Extraocular Muscle, both eyes of the client
coordinately moved in unison with parallel alignment.
o The client was able to read the newsprint held at a distance of 14
inches.
Ears and Hearing
Ears: The Auricles are symmetrical and has the same color with his facial skin.
The auricles are aligned with the outer canthus of eye. When palpating for the
texture, the auricles are mobile, firm and not tender. The pinna recoils when
folded. During the assessment of Watch tick test, the client was able to hear
ticking in both ears.
Nose and Sinus
Nose: The nose appeared symmetric, straight and uniform in color. There was no
presence of discharge or flaring. When lightly palpated, there were no tenderness
and lesions
Mouth:
o The lips of the client are uniformly pink; moist, symmetric and have a
smooth texture. The client was able to purse his lips when asked to
whistle.
o Teeth and Gums: There are no discoloration of the enamels, no
retraction of gums, pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink; moist,
soft, glistening and with elastic texture.
o The tongue of the client is centrally positioned. It is pink in color, moist
and slightly rough. There is a presence of thin whitish coating.
o The smooth palates are light pink and smooth while the hard palate has
a more irregular texture.
o The uvula of the client is positioned in the midline of the soft palate.
Neck:
o The neck muscles are equal in size. The client showed coordinated,
smooth head movement with no discomfort.
o The lymph nodes of the client are not palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands ascend
during swallowing but are not visible.
Thorax, Lungs, and Abdomen
Lungs / Chest: The chest wall is intact with no tenderness and masses. Theres
a full and symmetric expansion and the thumbs separate 2-3 cm during deep
inspiration when assessing for the respiratory excursion. The client manifested
quiet, rhythmic and effortless respirations.
The spine is vertically aligned. The right and left shoulders and hips are of the
same height.
Heart: There were no visible pulsations on the aortic and pulmonic areas. There
is no presence of heaves or lifts.
Abdomen: The abdomen of the client has an unblemished skin and is uniform in
color. The abdomen has a symmetric contour. There were symmetric movements
caused associated with clients respiration.
o The jugular veins are not visible.
o When nails pressed between the fingers (Blanch Test), the nails return
to usual color in less than 4 seconds.
Extremities
The extremities are symmetrical in size and length.
Muscles: The muscles are not palpable with the absence of tremors. They are
normally firm and showed smooth, coordinated movements.
Bones: There were no presence of bone deformities, tenderness and swelling.
Joints: There were no swelling, tenderness and joints move smoothly.
Nursing Assessment in Tabular Form
Assessment
Findings
Integumentary
When skin is pinched it goes to previous
Skin
state immediately (2 seconds).
With fair complexion.
With dry skin
Evenly distributed hair.
Hair
With short, black and shiny hair.
With presence of pediculosis Capitis.
Smooth and has intact epidermis
With short and clean fingernails and
Nails
toenails.
Convex and with good capillary refill time of
2 seconds.
Rounded, normocephalic and symmetrical,
Skull
smooth and has uniform
consistency.Absence of nodules or masses.
Symmetrical facial movement, palpebral
Face
fissures equal in size, symmetric nasolabial
folds.
Assessment
Findings
Eyes and Vision
Hair evenly distributed with skin intact.
Eyebrows
Eyebrows are symmetrically aligned and
have equal movement.
Eyelashes
Equally distributed and curled slightly
outward.
Skin intact with no discharges and no
Eyelids
discoloration.
Lids close symmetrically and blinks
involuntary.
Bulbar conjunctiva
Transparent with capillaries slightly visible
Palpebral Conjunctiva
Shiny, smooth, pink
Sclera
Appears white.
Lacrimal gland, Lacrimal sac,
No edema or tenderness over the lacrimal
Nasolacrimal duct
gland and no tearing.
Cornea
Transparent, smooth and shiny upon
inspection by the use of a penlight which is
Clarity and texture
held in an oblique angle of the eye and
moving the light slowly across the eye.
Has [brown] eyes.
Corneal sensitivity
Blinks when the cornea is touched through a
cotton wisp from the back of the client.
Black, equal in size with consensual and
direct reaction, pupils equally rounded and
reactive to light and accommodation, pupils
Pupils
constrict when looking at near objects,
dilates at far objects, converge when object
is moved toward the nose at four inches
distance and by using penlight.
Assessment
Findings
When looking straight ahead, the client can
see objects at the periphery which is done
by having the client sit directly facing the
Visual Fields
nurse at a distance of 2-3 feet.
The right eye is covered with a card and
asked to look directly at the student nurses
nose. Hold penlight in the periphery and ask
the client when the moving object is spotted.
Able to identify letter/read in the newsprints
Visual Acuity
at a distance of fourteen inches.
Patient was able to read the newsprint at a
distance of 8 inches.
Ear and Hearing
Color of the auricles is same as facial skin,
Auricles
symmetrical, auricle is aligned with the outer
canthus of the eye, mobile, firm, non-tender,
and pinna recoils after it is being folded.
External Ear Canal
Without impacted cerumen.
Hearing Acuity Test
Voice sound audible.
Able to hear ticking on right ear at a distance
Watch Tick Test
of one inch and was able to hear the ticking
on the left ear at the same distance
Nose and sinuses
Symmetric and straight, no flaring, uniform in
External Nose
color, air moves freely as the clients
breathes through the nares.
Mucosa is pink, no lesions and nasal
Nasal Cavity
septum intact and in middle with no
tenderness.
Mouth and Oropharynx
Symmetrical, pale lips, brown gums and able
to purse lips.
Assessment
Teeth
Findings
With dental caries and decayed lower molars
Central position, pink but with whitish
Tongue and floor of the mouth
coating which is normal, with veins
prominent in the floor of the mouth.
Tongue movement
Uvula
Moves when asked to move without difficulty
and without tenderness upon palpation.
Positioned midline of soft palate.
Gag Reflex
Present which is elicited through the use of a
tongue depressor.
Positioned at the midline without tenderness
Neck
and flexes easily. No masses palpated.
Coordinated, smooth movement with no
Head movement
discomfort, head laterally flexes, head
laterally rotates and hyperextends.
Muscle strength
With equal strength
Lymph Nodes
Non-palpable, non tender
Not visible on inspection, glands ascend but
Thyroid Gland
not visible in female during swallowing and
visible in males.
Thorax and lungs
Posterior thorax
Chest symmetrical
Spine vertically aligned, spinal column is
Spinal alignment
straight, left and right shoulders and hips are
at the same height.
Breath Sounds
Anterior Thorax
Abdomen
Abdominal movements
With normal breath sounds without
dyspnea.
Quiet, rhythmic and effortless respiration
Unblemished skin, uniform in color,
symmetric contour, not distended.
Symmetrical movements cause by
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Assessment
Findings
respirations.
Auscultation of bowel sounds
Upper Extremities
Lower Extremities
With audible sounds of 23 bowel
sounds/minute.
Without scars and lesions on both
extremities.
With minimal scars on lower extremities
Equal in size both sides of the body, smooth
coordinated movements, 100% of normal full
Muscles
movement against gravity and full
resistance.
Bones and Joints
No deformities or swelling, joints move
smoothly.
Mental Status
Language
Can express oneself by speech or sign.
Orientation
Oriented to a person, place, date or time.
Attention span
Level of Consciousness
Able to concentrate as evidence by
answering the questions appropriately.
A total of 15 points indicative of complete
orientation and alertness.
Motor Function
Gross Motor and Balance
Has upright posture and steady gait with
Walking gait
opposing arm swing unaided and
maintaining balance.
Standing on one foot with eyes closed
Heel toe walking
Toe or heel walking
Maintained stance for at least five (5)
seconds.
Maintains a heel toe walking along a straight
line
Able to walk several steps in toes/heels.
Fine motor test for Upper Extremities
8
Assessment
Finger to nose test
Findings
Repeatedly and rhythmically touches the
nose.
Alternating supination and pronation of
Can alternately supinate and pronate hands
hands on knees
at rapid pace.
Finger to nose and to the nurses finger
Perform with coordinating and rapidity.
Fingers to fingers
Perform with accuracy and rapidity.
Fingers to thumb
Rapidly touches each finger to thumb with
each hand.
Fine motor test for the Lower Extremities
Able to discriminate between sharp and dull
Pain sensation
sensation when touched with needle and
cotton.
